Invisible cost of care

DRUG TREND REPORT
UPDATED OCTOBER 2013 BY THE RESEARCH AND NEW SOLUTIONS LAB

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Published annually since 1997, the Express Scripts
Drug Trend Report provides the healthcare industry’s
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COMMERCIAL FEATURE ARTICLES
Timely, topical and in-depth analysis of issues particularly relevant to the population covered by employers, health maintenance organizations, health insurers,
union-sponsored benefit plans and third-party administrators.

THE DUAL ROLE OF CAREGIVERS WITH CHRONIC CONDITIONS

CAREGIVERS ARE
29% MORE LIKELY
TO USE ANXIETY
MEDICATIONS THAN
NON-CAREGIVERS

Behind the scenes of the traditional healthcare system exists a role that
is largely underappreciated: the role of caregiver. An estimated 42 million
Americans spend an average of 20 hours a week caring for friends or
loved ones.1 They provide a spectrum of care that ranges from making
phone calls to doctors and pharmacists to a daily routine that can include
hands-on services such as cooking, cleaning, bathing and administering
medications. But although many of these caregivers consider this noble
act fulfilling and satisfying, a large segment of this dedicated population
experiences reduced happiness, diminished engagement in daily activities, exacerbated health issues and
a nonexistent work-life balance. In this article, we explore the cost of caregiving and the complications
of the caregiver role.
Caregiving: A Closer Look
In providing unpaid care for an acquaintance, friend or family member, caregivers often sacrifice
considerable time and money. This personal sacrifice can create a great deal of stress2 for many
caregivers, sometimes leading them to neglect their own health and wellness. Yet caregivers are often
at risk for both mental and physical health problems as they cope with the problems of others.3
As the population in need of health-related care grows, the demand for caregivers will increase as well.
According to the U.S. Department of Health and Human Services’ Administration on Aging, the number
of Americans age 65 and older is expected to top 70 million in 2030.4 Because older adults are the
demographic group that is most likely to require caregiver services,5 this growing population makes it
Drug Trend Report — Commercial 4

imperative to consider the dual role that caregivers play in the healthcare system. Caregivers don’t
just provide care and support for other patients; often, they are patients themselves, with their own
healthcare needs.
To better understand the prevalence of caregiving among our members, and to recognize the special
role-related challenges that they may face, Express Scripts conducted a telephone survey of members
age 18 to 65 who were taking at least one prescription drug regularly for a long-term or chronic health
condition. The 12,005 members who participated in the survey were questioned about their general
health, well-being and medication-taking behavior. They were also asked: “In the past month, have you
provided unpaid care to an adult relative or friend to help them take care of themselves?” The survey
revealed that 34.6% of respondents had provided such care during the previous month. The amount of
time spent providing care was not taken into consideration.
On average, caregivers were 52 years old, and almost two-thirds reported providing care for a parent,
sibling, other relative or friend rather than to a spouse or an adult child in the month prior to the survey.
Further, caregivers were more likely to be female than male (62.9% vs. 37.1%), and about one-third
were providing care for more than one person. Providing care for more than one person at a time can
intensify stress and increase the amount of resources devoted to caregiving.
The demands of caregiving appeared to change frequently, with caregivers reporting that they provided
shifting levels of care at different times. When asked how their caregiving had changed in the past
month, 35.6% of Express Scripts caregivers said they had increased the amount of care they were
providing; by contrast, 14.9% had decreased the amount of care. Caregiving appeared, in general, to
be an ongoing endeavor, with only 8.5% of caregivers saying they were new to the role and an even
smaller 3.8% saying they had stopped providing care altogether in the past month.
Providing care over a distance was also something surveyed caregivers had to contend with, as only one
in five Express Scripts caregivers resided in the same households as the patients in their care. Among
the other 80% of caregivers, more than half (52.0%) lived within 15 miles of the primary recipient of
their care, but 27.3% lived more than 15 miles away. Traveling to provide care affects the type of care
and degree of supervision that can be provided. If the necessary care is time-sensitive (e.g., providing
transportation to physician appointments) or if hands-on interaction is required (e.g., bathing or ensuring
that medications are taken as prescribed), long distances involved in caregiving can become problematic.
Moreover, already demanding requirements for time and energy are amplified when caregivers themselves
have physicians to visit and medications to manage.
Caregiver, Patient or Both?
We also reviewed pharmacy claims to determine which prescription medications caregivers were taking
including those to treat chronic illnesses that are associated with stress, such as high blood pressure/
heart disease, high cholesterol, depression and anxiety. Medications for high blood pressure/heart
disease topped the list of prescription medications that caregivers were taking, followed by medications
for high cholesterol and depression. (See table on the next page.) Although the prevalence of use of
drugs to treat the top 10 conditions was somewhat similar among caregivers and noncaregivers (survey
respondents who had not provided care in the previous month), utilization of medications in the therapy
classes shown in the table below (with the exception of drugs to treat high cholesterol and to treat
asthma) was consistently higher among caregivers than noncaregivers. This finding isn’t surprising
given the reduced amount of time available to manage one’s own health as a result of this added role.


As further evidence of the stresses associated with the dual caregiver-patient role, the survey found
that even after controlling for factors such as age, gender and income, Express Scripts caregivers were
more likely to rate themselves as being in poorer health — fair, poor or very poor health as compared to
good, very good, or excellent health — than were noncaregivers (14.6.% vs. 12.4%). Not surprisingly,
a higher proportion of caregivers also reported being “not very happy” or “not at all happy” than did
noncaregivers (5.3% vs. 3.5%).
Being a caregiver also was associated with at least one negative health behavior. The review of pharmacy
claims showed that only 63.9% of caregivers were adherent to all of their medications compared to
67.8% of noncaregivers. Particularly important is the finding that 73.2% of noncaregivers took their
antidepressant medications as prescribed at least 80% of the time, whereas only 66.6% of caregivers
achieved this same rate of compliance. Through noncompliance with their own antidepressant
medications, caregivers may affect their own health as well as their ability to provide quality, reliable
care to those for whom they are caring.
The Future: A Simpler Life for Caregivers
Those receiving the care think of caregivers as heroes. Others consider them to be the safety net of our
healthcare system as estimates project the economic value of their unpaid contributions to be approximately
$450 billion,1 a figure that far exceeds national spending for home healthcare and nursing home care.6
In either case, caregivers are vital to providing healthcare in the U.S., and their obligations will increase
as the population in need of care grows. Because caregivers’ actions enable individuals to live in
community settings rather than institutions, they will become increasingly important as time goes on.
After all, if we don’t take care of our caregivers, they will soon be the ones needing care.


As the healthcare industry works toward solutions to simplify the lives of caregivers, we wonder what
would happen if we began to look at this role differently. Perhaps technology, actionable data and
advanced screening can help us better understand and meet the special needs of this group as they
have in other areas of our industry. Express Scripts is committed to making this critical role easier.

Footnotes
1. einberg L, Reinhard SC, Houser A, Choula R. Valuing the Invaluable: The Growing Contributions and Costs of Family
F
Caregiving. Available at: http://assets.aarp.org/rgcenter/ppi/ltc/i51-caregiving.pdf. Accessed July 22, 2013.
2. earlin LI, Mullan JT, Semple SJ, Skaff MM. Caregiving and the stress process: an overview of concepts and their
P
measures. Gerontologist. 1990;30(5):583–594.
3. avaie-Waliser M, Feldman PH, Gould DA, Levine CL, Kuerbis AN, Donelan K. When the caregiver needs care: the plight
N
of vulnerable caregivers. Am J Pub Health. 2002;92(3):409–413.
4. epartment of Health and Human Services Administration on Aging. Aging statistics. May 8, 2013. Available at:
D
http://www.aoa.gov/AoARoot/Aging_Statistics/index.aspx. Accessed July 2, 2013.
5. tanton MW. The high concentration of U.S. health care expenditures. Research in Action, Issue 19. 2006. Agency for
S
Healthcare Research and Quality, Rockville, MD. Available at: http://www.ahrq.gov/research/findings/factsheets/costs/
expriach/index.html#HowAre. Accessed July 2, 2013.
6. enters for Medicare and Medicaid Services. National health expenditures 2011 highlights. January 2013. Available
C
at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/
downloads/highlights.pdf. Accessed July 23, 2013.


SPECIALTY FEATURE ARTICLES
Timely, topical and in-depth analysis focusing on specialty issues particularly relevant
to the population covered by employers, health maintenance organizations, health
insurers, union-sponsored benefit plans and third-party administrators.

THE COST-EFFECTIVENESS OF EVIDENCE-BASED BREAST CANCER
TREATMENT GUIDELINES

Millions of Americas are fighting cancer every day, and clinicians are fighting right along with them.
To help clinicians make the best treatment decisions, evidence-based guidelines have been developed
and are continually refined as new solutions are discovered. Guidelines for many diseases, including
cancer, direct treatment decisions and optimize outcomes based on impartial, systematic appraisal of
research data about treatment success from both clinical trials and physician practices.1 The costs of
treatment are rarely considered in developing these guidelines.2
With the costs for cancer treatment continuing to rise, Express Scripts researchers examined the
relationship between breast cancer drug therapy based on established guidelines and cancer treatment
costs. The study revealed that more than 20% of certain breast cancer patients are not treated according
to guidelines and that this off-guideline treatment is needlessly costing the healthcare system an average
of almost $8,000 more per patient per year.
Experts, Evidence and Effectiveness
Cancer-therapy guidelines help physicians manage complex treatments by suggesting appropriate
clinical pathways that include combinations, sequences and doses of cancer medications. They also
consider patient-related factors — including age and menopausal status — as well as disease-specific
inputs such as cancer stage at diagnosis and the presence of biomarkers (biological indicators of
specific conditions or processes). Although guidelines are intended to provide the highest-quality care,
the most favorable outcomes and the least amount of waste, treatment costs have not historically been
considered when guidelines are established.2

For cancer treatment, advocacy groups such as the National Comprehensive Cancer Network (NCCN) and
the American Society of Clinical Oncology (ASCO) serve as important sources of unbiased, authoritative
recommendations. Guidelines and clinical literature published by these organizations are updated
continually with the goal of giving providers access to the best, most current scientific evidence on
which to base their treatment decisions.3
The Rising Cost of Cancer
Fighting cancer is a complex and expensive process. Research from the National Cancer Institute
estimates the national direct cost of cancer at $124.6 billion annually. Breast cancer, colorectal
cancer and lung cancer are among the most common cancer types in the U.S. and are also the most
expensive to treat. In 2010, treatment costs reached $16.5 billion for breast cancer, $14.1 billion for
colorectal cancer and $12.1 billion for lung cancer.4
Drug costs typically have been lower than the costs of other cancer treatment options (such as mastectomy
for breast cancer), even in patients with more advanced stages of the disease.5 However, many new
drug therapies that target cancer tumors with specific genetic profiles are very expensive.6 Internal
analyses of Express Scripts data from 2012 found that two-thirds of the cancer-drug prescriptions that
Express Scripts members filled in 2012 had an average cost of at least $1,000 per prescription. The
average cost for some individual cancer drugs was as high as $33,000 per prescription.
As prescription drug costs for cancer treatment rise — the cost of some cancer medications can reach
more than $200,000 per course of treatment7 — affordability and cost-effectiveness of treatment become
important issues for plan sponsors. Therefore, Express Scripts researchers sought to examine the
relationship between on-guideline treatment for breast cancer — that is, whether breast cancer drug
therapy was prescribed according to NCCN guidelines — and cancer treatment costs. We determined the
proportion of patients who received on-guideline treatment and the proportion who received off-guideline
treatment, and then compared the cost of cancer-related therapy for the two groups of patients.
Breast Cancer Treatment Analysis
The study focused on chemotherapy for female breast cancer patients. One of the three most prevalent
cancer types,8 breast cancer has well-established therapies and treatment protocols. Recent estimates
suggest that 90% of female breast cancer patients live at least five years after successful treatment.9
For breast cancer patients, the presence of biomarkers helps to guide treatment course. One such
biomarker is human epidermal growth factor receptor 2 (HER2). HER2, when expressed in breast
cancer, is associated with more aggressive disease.10 Evidence suggests that targeted therapy with a
medication called Herceptin® (trastuzumab), in combination with other similar cancer medications,
decreases the risk of relapse for women with HER2-positive breast cancer.11,12
Using the Truven Health MarketScan® Commercial Claims Database,13 the study evaluated integrated
medical and pharmacy claims of 1,384 female breast cancer patients age 18 to 63. Newly diagnosed
breast cancer patients who were being treated with injectable or oral solid prescription medications in
2009 and 2010 in any of several settings — hospitals, infusion centers, outpatient clinics, physicians’
offices or their own homes — were identified and followed for one year. The observed cancer drug regimens
were compared with 2012 NCCN recommendations to determine if patients were being treated according
to evidence-based guidelines, and on this basis patients were assigned to either an on-guideline group
or an off-guideline group. Guidelines from 2012 were used in order to account for treatment with
newer therapies which may have been used in practice in 2009 or 2010, but had not yet made
their way into evidence-based guidelines. The use of Herceptin or other HER2-targeted therapies was
assumed to be an indication of a patient’s HER2-positive status.

Study Results: Potential Savings
The study revealed, first, that approximately one in five patients receiving chemotherapy for breast
cancer was treated off-guideline and, second, that on-guideline treatment rates varied by HER2
biomarker status. Of the 1,384 patients in the study, 289 (21.1%) were treated off-guideline. Further,
most patients receiving off-guideline therapy (62.6%) were HER2-negative, which means they did not
test positive for the presence of the HER2 biomarker. (See figures below.)

Evaluating the relationship between guideline adherence and treatment costs showed that direct medical
costs associated with treating breast cancer were 11.8% higher for patients who were being treated
off-guideline. (See table below.) On average, each patient incurred an additional $7,959 in annual
treatment costs when evidence-based guidelines were not followed. In addition, annual drug costs billed
solely through the pharmacy benefit were slightly higher for patients whose treatment did not adhere to
guidelines than for patients who were being treated according to guidelines ($4,203 vs. $4,145).


Summary
Although this research assumed that HER2 status was indicated accurately by the presence of prescriptions
for HER2-targeted therapies, it is possible that HER2-negative patients were being treated with
HER2-targeted therapies. This type of treatment would not have been appropriate for patients who
were HER2-negative; therefore this assumption may have actually underestimated the rate of
off-guideline treatment. In addition, because 2012 NCCN guidelines were used to compare treatments
which occurred in 2009 or 2010, some misclassification of on- and off-guideline care may have
occurred. Despite these limitations, however, the study still revealed that more than 20% of breast
cancer patients were not treated according to evidence-based guidelines, with adherence to NCCN
treatment recommendations being the determining factor. Further, patients who were treated according
to the guidelines had lower breast cancer-related healthcare costs than did those treated off-guideline.
Together, these results demonstrate that following evidence-based treatment guidelines can help lower
healthcare costs among patients being treated with specialty cancer medications.

Footnotes
1. rimshaw J, Eccles M, Russell I. Developing clinically valid practice guidelines. J Eval Clin Pract. 1995;1(1):37–48.
G
2. amsey S, Shankaran V. Managing the financial impact of cancer treatment: the role of clinical practice guidelines.
R
J Natl Compr Canc Netw. 2012;29(8):943–953.
3. ational Comprehensive Cancer Network. NCCN guidelines® and derivative information products: user guide. 2013.
N
Available at: http://www.nccn.org/clinical.asp. Accessed July 6, 2013.
4. ational Cancer Institute. The cost of cancer. February 18, 2011. Available at: http://www.cancer.gov/aboutnci/
N
servingpeople/cancer-statistics/costofcancer. Accessed June 24, 2013.
5. adice D, Redaelli A. Breast cancer management: quality-of-life and cost considerations. Pharmacoeconomics.
R
2003;21(6):383–396.
6. ulcahy N. Efficacy, not price, of new breast cancer drug is welcomed. Medscape Today. March 1, 2013. Available at:
M
http://www.medscape.com/viewarticle/780107. Accessed July 12, 2013.
7. oozner M. High cost of new cancer drugs sparks new care struggle. Kaiser Health News. January 23, 2012. Available
G
at: http://www.kaiserhealthnews.org/stories/2012/january/23/fiscal-times-cancer-drugs-affordable.aspx. Accessed
June 28, 2013.
8. ational Cancer Institute. Common cancer types. January 25, 2013. Available at: http://www.cancer.gov/cancertopics/
N
types/commoncancers. Accessed June 28, 2013.
9. merican Cancer Society. Cancer facts figures. 2013. Available at: http://www.cancer.org/acs/groups/content/
A
@epidemiologysurveilance/documents/document/acspc-036845.pdf. Accessed June 28, 2013.
10. lamon DJ, Clark GM, Wong SG, Levin WJ, Ullrich A, McGuire WL. Human breast cancer: correlation of relapse and
S
survival with amplification of the HER2/neu oncogene. Science. 1987;235(4785):177–182.
11. oldhirsch A, Glick JH, Gelber RD, et al. Meeting highlights: international expert consensus on the primary therapy of
G
early breast cancer 2005. Ann Oncol. 2005; 16(10):1569–1583.
12. iccart-Gebhart MJ, Procter M, Leyland-Jones B, et al. Trastuzumab after adjuvant chemotherapy in HER2-positive
P
breast cancer. N Engl J Med. 2005;353(16):1659–1672.
13. ruven Health Analytics. MarketScan® Commercial Claims and Encounters Database. Ann Arbor, MI. 2007–2010.
T


TOTAL TREND
The Commercial Total Trend measures the rate of change in total spend driven
by utilization and unit cost for the population covered by employers, health
maintenance organizations, health insurers, union-sponsored benefit plans and
third-party administrators.

COMPONENTS OF COMMERCIAL TREND, 2012
TREND
PMPY SPEND

UTILIZATION

UNIT COST

TOTAL

Traditional

$639.66

0.6%

-2.2%

-1.5%

Specialty

$207.19

-0.4%

18.7%

18.4%

TOTAL OVERALL

$846.85

0.6%

2.1%

2.7%

January–December 2012 compared to same period in 2011

Key Insights
• nnual trend was 2.7%, driven by higher drug costs for specialty medications, which represent
A
24.5% of total PMPY spend. Compared to 2011, 2012 utilization was up 0.6% while unit costs
increased 2.1%.
• The impact of specialty drugs on PMPY spend and overall trend is expected to continue. The Food
and Drug Administration (FDA) approved 22 new specialty medications in 2012, some with price
tags worth tens of thousands of dollars per month. For information on other newly approved drugs,
see Brand Approvals.
• Traditional drugs had an annual decline in cost and total trend, due to the effect of the patent cliff
— the wave of blockbuster patent expirations for drugs in many of the top therapy classes. Greater
availability of generic alternatives and increased competition decreased costs to both payers and
patients.


TRADITIONAL THERAPY CLASS
The Commercial Traditional Therapy Class Trend section highlights key traditional
therapy classes and explains factors driving trend for the population covered by
employers, health maintenance organizations, health insurers, union-sponsored
benefit plans and third-party administrators.

TRADITIONAL TREND BY THERAPY CLASS
Components of Trend for the Top 10 Commercial
Traditional Therapy Classes, Ranked by PMPY Spend, 2012
TREND
THERAPY CLASS

PMPY SPEND

UTILIZATION

UNIT COST

TOTAL

Diabetes

$79.24

1.5%

9.5%

11.0%

High Blood Cholesterol

$66.13

-0.8%

-9.7%

-10.5%

High Blood Pressure/Heart Disease

$47.61

1.5%

-5.3%

-3.9%

Asthma

$43.42

1.5%

0.4%

2.0%

Ulcer Disease

$36.61

2.6%

-8.7%

-6.1%

Depression

$34.71

3.2%

-8.4%

-5.3%

Attention Disorders

$30.58

8.8%

5.4%

14.2%

Mental/Neurological Disorders

$27.12

0.1%

-12.1%

-12.1%

Pain

$23.71

0.7%

-5.7%

-5.0%

Infections

$17.46

-2.9%

-13.8%

-16.7%

Other

$233.07

-0.3%

0.3%

0.0%

TOTAL TRADITIONAL

$639.66

0.6%

-2.2%

-1.5%

Key Insights
• Utilization was up for 8 of the top 10 traditional therapy classes, while unit costs decreased in 7. This
pattern generally reflects the impact of the patent cliff, in which many brand blockbuster medications
lost patent protection, opening the market to generic competition and yielding lower drug costs.
• Diabetes medications had the highest traditional PMPY spend. Unit costs had the greatest impact on
total trend, and were driven by cost increases among insulins including Humulin® R (Regular insulin
human injection, USP (rDNA origin)) and Lantus® (insulin glargine).
• Utilization of medications used to treat depression increased 3.2%, but costs decreased 8.4%,
leading to negative overall trend. Some of the increased use of antidepressants in recent years may

be due to the economic crisis and associated turmoil in the labor market.1 The impact of the patent
cliff on costs was seen as Lexapro® (escitalopram), the last remaining brand medication in the most
commonly used class of antidepressants, lost patent protection and the original generic ended its
exclusivity arrangement in 2012. Both increased competition and drove lower costs for the class.
• he largest increase in total spend was for medications used to treat attention disorders, impacted
T
by both an 8.8% increase in utilization and a 5.4% increase in costs. There has been a notable
increase in utilization of these drugs in adult patients2 and treatment guidelines allow use in even
younger patients than previously indicated.3 Costs were affected by the shortage in 2012 of active
ingredients contained in many of the medications in this class.4

Footnotes
1. ascade E, Kalali AH, Kwentus JA, Bharmal M. Trends in CNS prescribing following the economic slowdown. Psychiatry
C
(Edgmont). 2009; 6(1): 15-17.
2. oyer CS. Challenges of adult ADHD. Amednews.com August 27, 2012. Available at: http://www.ama-assn.org/
M
amednews/2012/08/27/hlsa0827.htm. Accessed February 3, 2013.
3. Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management.

ADHD: clinical practice guidelines for the diagnosis, evaluation and treatment of attention-deficit/hyperactivity disorder
in children and adolescents. Pediatrics. 2011; 128(5): 1007-1022.
4. S Food and Drug Administration. Current drug shortages. May 11, 2012. Available at: http://www.fda.gov/Drugs/
U
DrugSafety/DrugShortages/ucm050792.htm. Accessed January 24, 2013.


DIABETES
PHARMACY-RELATED WASTE
$

37.9

%

of patients are

SAVINGS OPPORTUNITY

PHARMACY
CHOICES
DRUG
CHOICES

NONADHERENT

to medication therapy3

$22.28
$22.84

57 %

$45.13

$45.13 PMPY=
PMPY

TOP DRUGS BY MARKET SHARE

16.66%

0%

metformin

50%

7.0%

glipizide

33.33%

28.6%

Lantus® (insulin glargine)

OF PMPY SPEND

6.3%

Onetouch® Ultra® Test Strips

4.9%

Januvia® (sitagliptin)

4.5%

BY THE NUMBERS

$

79.24
Cost PMPY

0.961

5.9%

$

82.48

#Rx PMPY

Prevalence

Average Cost/Rx

*Metrics are presented as an annualized estimate based on the previous calendar year.


HIGH BLOOD CHOLESTEROL
$

27.2

%

of patients are

SAVINGS OPPORTUNITY

PHARMACY
CHOICES
DRUG
CHOICES

NONADHERENT


$16.02
$30.79
$46.82
PMPY


0%

16.66%

simvastatin

50%

11.1%

pravastatin

33.33%

20.6%

Crestor® (rosuvastatin)

OF PMPY SPEND

30.1%

atorvastatin

70.8 %

=

10.0%

lovastatin

3.7%

BY THE NUMBERS

$

66.13
Cost PMPY

1.382

13.4%

#Rx PMPY

Prevalence

$

47.87

Average Cost/Rx



HIGH BLOOD PRESSURE/HEART DISEASE
$

28.1

%

of patients are

SAVINGS OPPORTUNITY

PHARMACY
CHOICES
DRUG
CHOICES

NONADHERENT


$11.51
$17.34
$28.85
PMPY


0%

16.66%

lisinopril

6.0%

losartan

50%

7.8%

atenolol

33.33%

11.1%

metoprolol succinate

OF PMPY SPEND

16.0%

amlodipine

60.6 %

=

5.4%

BY THE NUMBERS

$

47.61
Cost PMPY

2.432

17.9%

#Rx PMPY

Prevalence

$

19.57

Average Cost/Rx



ASTHMA
$

80.2%
53.8%

pediatric
adult

of patients are

SAVINGS OPPORTUNITY

PHARMACY
CHOICES
DRUG
CHOICES

NONADHERENT


-$1.58
$3.89
$2.32
PMPY


0%

16.66%

Proair® HFA (albuterol)

10.8%

Ventolin® HFA (albuterol)

50%

14.2%

montelukast

33.33%

16.7%

Advair® Diskus (fluticasone propionate and salmeterol)

OF PMPY SPEND

17.1%

Singulair® (montelukast)

5.3 %

=

7.6%

BY THE NUMBERS

$

43.42
Cost PMPY

0.458

8.9%

$

94.73

#Rx PMPY

Prevalence

Average Cost/Rx



ULCER DISEASE
$

A 10% decrease in proton pump inhibitor
adherence among NSAID users is
associated with a 6% increase in the risk of
gastrointestinal complications.

PHARMACY
CHOICES

$10.21

DRUG
CHOICES

Jonasson C, Hatlebakk JG, Lundell L, et al. Association between
adherence to concomitant proton pump inhibitor therapy in current
NSAID users and upper gastrointestinal complications.
Eur J Gastroenterol Hepatol. 2013; 25(5): 531-538.


SAVINGS OPPORTUNITY

$15.92
$26.13
PMPY

0%

16.66%

omeprazole

6.4%

lansoprazole

50%

13.8%

ranitidine

33.33%

20.8%

pantoprazole

OF PMPY SPEND

41.6%

Nexium® (esomeprazole)

71.4 %

=

5.9%

BY THE NUMBERS

$

36.61
Cost PMPY

0.633

8.8%

$

57.85

#Rx PMPY

Prevalence

Average Cost/Rx



DEPRESSION
$

39.9

%

of patients are

SAVINGS OPPORTUNITY

PHARMACY
CHOICES
DRUG
CHOICES

NONADHERENT


$9.07
$7.93
$17.00
PMPY


0%

16.66%

sertraline

50%

11.3%

venlafaxine

33.33%

13.5%

fluoxetine

OF PMPY SPEND

16.7%

bupropion

49 %

18.0%

citalopram

=

9.1%

BY THE NUMBERS

$

34.71
Cost PMPY

0.903

10.5%

#Rx PMPY

Prevalence

$

38.44

Average Cost/Rx



ATTENTION DISORDERS
$

Adherence, persistence and rates of
switching are significantly lower in
patients using long-acting stimulants to
treat attention disorders compared to
short-acting formulations.

SAVINGS OPPORTUNITY

PHARMACY
CHOICES
DRUG
CHOICES

$0.09
-$14.97
PMPY

Palli SR, Kamble PS, Chen H, Aparasu RR. Persistence of stimulants
in children and adolescents with attention-deficit/hyperactivity
disorder. J Child Adolesc Psychopharmacol. 2012; 22(2): 139-148.


-$15.06

0%

16.66%

amphetamine and dextroamphetamine

OF PMPY SPEND

33.33%

50%

21.9%

Vyvanse® (lisdexamfetamine)

0%

34.5%

methylphenidate

=

15.8%

Focalin® XR (dexmethylphenidate)

4.6%

Strattera® (atomoxetine)

4.3%

BY THE NUMBERS

$

30.58
Cost PMPY

0.205

2.6%

#Rx PMPY

Prevalence

$

148.84

Average Cost/Rx



MENTAL/NEUROLOGICAL DISORDERS
$

41.7

%

of patients are

SAVINGS OPPORTUNITY

PHARMACY
CHOICES
DRUG
CHOICES

NONADHERENT


$7.34
$4.86
$12.20
PMPY


0%

16.66%

donepezil

50%

10.7%

risperidone

33.33%

11.0%

Namenda® (memantine)

OF PMPY SPEND

12.3%

quetiapine

45 %

15.0%

Abilify® (aripiprazole)

=

10.7%

BY THE NUMBERS

$

27.12
Cost PMPY

0.159

1.9%

#Rx PMPY

Prevalence

$

170.20

Average Cost/Rx



PAIN
$

Nonadherence in chronic pain patients
is more closely related to concerns about
medication and withdrawal than to level of
pain or frequency of side-effects.

SAVINGS OPPORTUNITY

PHARMACY
CHOICES
DRUG
CHOICES

$13.54

Broekmans S, Vanderschueren S. Concerns about medication and
medication adherence in patients with chronic pain recruited from
general practice. Evid Based Nurs. 2012; 15(2): 42-43.


$4.11

$17.65
PMPY

0%

16.66%

hydrocodone and acetaminophen

33.33%

50%

8.3%

amitriptyline

OF PMPY SPEND

12.4%

oxycodone and acetaminophen

74.5 %

41.3%

tramadol

=

5.9%

oxycodone

4.1%

BY THE NUMBERS

$

23.71
Cost PMPY

0.745

18.2%

#Rx PMPY

Prevalence

$

31.83

Average Cost/Rx



INFECTIONS
$

Adherence to twice-daily regimens of
amoxicillin/clavulanic acid therapy is
significantly higher than adherence to
thrice-daily dosing regimens.

SAVINGS OPPORTUNITY

PHARMACY
CHOICES

$0.79

DRUG
CHOICES

$8.12
$8.92
PMPY

Llor C, Bayona C, Hernandez S, et al. Comparison of adherence
between twice- and thrice-daily regimens of amoxicillin/clavulanic
acid. Respirology. 2012; 17(4): 687-692.


0%

16.66%

azithromycin

50%

7.1%

sulfamethoxazole and trimethoprim

33.33%

8.6%

ciprofloxacin

OF PMPY SPEND

16.5%

amoxicillin and potassium clavulanate

51.1 %

20.8%

amoxicillin

=

6.7%

BY THE NUMBERS

$

17.46
Cost PMPY

0.881

37.7%

#Rx PMPY

Prevalence

$

19.80

Average Cost/Rx



SPECIALTY THERAPY CLASS
The Commercial Specialty Therapy Class Trend section highlights key specialty
employers, health maintenance organizations, health insurers, union-sponsored
benefit plans and third-party administrators.

SPECIALTY TREND BY THERAPY CLASS
Components of Trend for the Top 10 Commercial
Specialty Therapy Classes, Ranked by PMPY Spend, 2012
TREND
THERAPY CLASS

PMPY SPEND

UTILIZATION

UNIT COST

TOTAL

Inflammatory Conditions

$50.62

9.0%

14.0%

23.0%

Multiple Sclerosis

$37.98

0.5%

17.3%

17.8%

Cancer

$31.98

3.4%

22.3%

25.8%

HIV

$20.78

-2.1%

11.1%

9.0%

Hepatitis C

$7.82

28.9%

4.8%

33.7%

Growth Deficiency

$7.41

1.7%

7.7%

9.5%

Anticoagulant

$6.74

1.7%

0.3%

2.1%

Pulmonary Hypertension

$5.71

5.1%

6.2%

11.3%

Respiratory Conditions

$5.56

1.5%

25.7%

27.2%

Transplant

$4.92

2.2%

-6.9%

-4.7%

$27.68

-24.9%

43.7%

18.8%

$207.19

-0.4%

18.7%

18.4%

Other
TOTAL SPECIALTY

Key Insights
• Inflammatory conditions such as rheumatoid arthritis (RA) continued to have the highest PMPY spend,
driven by a 9.0% increase in utilization and a 14.0% increase in costs, for a total trend of 23.0% in
2012. A new RA drug, Xeljanz® (tofacitinib), is the first oral disease modifying medication to be approved
in this therapy class. Taking it is more convenient than using injectable medications, and the drug is
associated with significant improvement in symptoms.1 Xeljanz is likely to attract new and existing
medication users away from other drugs. Some of the cost increases for older, injectable treatments in
this class may be explained by concerns over future declining market share as oral medications, such as
Xeljanz, become available.

• Utilization and costs for cancer medications increased 3.4% and 22.3%, respectively. Much of the
increase in costs is driven by new drugs developed to treat unique genetic or proteomic profiles, a
trend that has increased in recent years. Developing targeted medications requires additional research
and incurs additional costs; but costs also increase as more patients initiate therapy on these newer,
more-expensive therapies rather than trying older oncology medications as first-line therapies.
• Although utilization of HIV medications decreased 2.1%, 2012 costs increased by 11.1%, leading to
an overall 9.0% increase in total spend. The patterns of change reflect switches from older, multi-pill
regimens, some of which are available as generics, to more expensive combination therapies such as
Atripla® (efavirenz, tenofovir, emtricitabine) and Truvada® (tenofovir, emtricitabine), which contain
multiple active ingredients in a single pill.
• Hepatitis C continues to lead total trend for specialty drugs, driven almost entirely by increased utilization
of the two new drugs introduced in May 2011, Incivek® (telaprevir) and Victrelis® (boceprevir).

Footnotes
1. an Vollenhoven RF, Fleischmann R, Cohen S, et al. Tofacitinib or adalimumab versus placebo in rheumatoid arthritis.
V
N Eng J Med. 2012; 367(6): 508-519.


INFLAMMATORY CONDITIONS

40.4

%

of patients are

Spend in
Medical Benefit

NONADHERENT



31.9 %

0%

16.66%

Humira® (adalimumab)

50%

43.2%

Enbrel® (etanercept)

33.33%

42.3%

Cimzia® (certolizumab)

3.2%

Simponi® (golimumab)

2.9%

Stelara® (ustekinumab)

2.8%

BY THE NUMBERS

$

50.62

PMPY Spend

0.023

0.27%

#Rx PMPY

Prevalence

$

2,212.73
Average Cost/Rx



MUTIPLE SCLEROSIS

26.3

%

of patients are

Spend in
Medical Benefit

NONADHERENT



10.5 %

0%

33.33%

16.66%

Copaxone® (glatiramer)

34.3%

Avonex® (interferon beta-1a)

18.5%

Rebif® (interferon beta-1a)

14.9%

Betaseron® (interferon beta-1b)

9.6%

Gilenya® (fingolimod)

50%

8.2%

BY THE NUMBERS

$

37.98

PMPY Spend

0.011

0.10%

#Rx PMPY

Prevalence

$

3,583.85
Average Cost/Rx



CANCER

40.9

%

of patients are

Spend in
Medical Benefit

NONADHERENT



76.5 %

16.66%

0%

methotrexate

11.8%

Xeloda® (capecitabine)

10.3%

Revlimid® (lenalidomide)

10.0%

Lupron Depot® (leuprolide)

50%

17.6%

Gleevec® (imatinib)

33.33%

8.6%

BY THE NUMBERS

$

31.98

PMPY Spend

0.009

0.17%

#Rx PMPY

Prevalence

$

3,682.32
Average Cost/Rx



HIV

22.5

%

of patients are

Spend in
Medical Benefit

NONADHERENT



0%

0%

16.66%

Atripla® (efavirenz, emtricitabine and tenofovir)

16.0%

Norvir® (ritonavir)

12.4%

Isentress® (raltegravir)

7.8%

Reyataz® (atazanavir)

50%

19.2%

Truvada® (emtricitabine and tenofovir)

33.33%

7.0%

BY THE NUMBERS

$

20.78

PMPY Spend

0.022

0.13%

#Rx PMPY

Prevalence

$

947.56

Average Cost/Rx



HEPATITIS C
Sustained virologic response in hepatitis C
patients decreases when patients are less
than 60% adherent to dosing regimens
of boceprevir.

Spend in
Medical Benefit

Gordon SC, Lawitz EJ, Bacon BR, et al. Adherence to assigned
dosing regimen and sustained virologic response among hepatitis
c genotype 1 treatment-naive and peg/ribavirin treatment failures
treated with boceprevir plus peginterferon alfa-2b/ribavirin.
J Hepatol 2011;54 (Supplement 1):S173–S174.


0.5 %

0%

16.66%

Pegasys® (peginterferon alfa-2a)

16.7%

Ribapak® (ribavirin)

15.5%

ribavirin

11.6%

Incivek® (telaprevir)

50%

31.8%

Ribasphere® (ribavirin)

33.33%

10.3%

BY THE NUMBERS

$

7.82

PMPY Spend

0.002

0.02%

#Rx PMPY

Prevalence

$

3,284.27
Average Cost/Rx



GROWTH DEFICIENCY

36.2

%

of patients are

Spend in
Medical Benefit

NONADHERENT



2.3 %

0%

16.66%

Norditropin® Flexpro® (somatropin)

21.9%

Humatrope® (somatropin)

18.1%

Nutropin® AQ Nuspin™ (somatropin)

9.9%

Nutropin® AQ (somatropin)

50%

28.6%

Genotropin® (somatropin)

33.33%

5.6%

BY THE NUMBERS

$

7.41

PMPY Spend

0.002

0.03%

#Rx PMPY

Prevalence

$

3,146.71
Average Cost/Rx



ANTICOAGULANTS
Noncompliant high-risk warfarin patients
have a 3 times greater risk of recurrence
of venous thromboembolism than patients
who are compliant.

Spend in
Medical Benefit

Chen SY, Wu N, Gulseth M, et al. One-year adherence to warfarin
treatment for venous thromboembolism in high-risk patients and
its association with long-term risk of recurrent events.
J Manag Care Pharm. 2013; 19(4): 291-301.

enoxaparin

7.2 %

33.33%

0%

66.66%

99%

85.2%

fondaparinux

6.5%

Lovenox® (enoxaparin)

3.9%

Fragmin® (dalteparin)

3.3%

Arixtra® (fondaparinux)

1.0%

BY THE NUMBERS

$

6.74

PMPY Spend

0.007

0.33%

#Rx PMPY

Prevalence

$

985.18

Average Cost/Rx



PULMONARY HYPERTENSION

24.7

%

of patients are

Spend in
Medical Benefit

NONADHERENT



27.6 %

0%

33.33%

16.66%

Revatio® (sildenafil)

37.9%

Tracleer® (bosentan)

22.3%

Adcirca® (tadalafil)

19.5%

Letairis® (ambrisentan)

50%

13.1%

sildenafil

3.2%

BY THE NUMBERS

$

5.71

PMPY Spend

0.002

0.01%

#Rx PMPY

Prevalence

$

3,748.39
Average Cost/Rx



RESPIRATORY CONDITIONS
The incidence rate of pulmonary exacerbations in nonadherent patients taking
medications such as dornase alfa and
tobramycin was 2.43 times that of patients
who were adherent to their medications.

33.8 %

Spend in
Medical Benefit

Eakin MN, Bilderback A, Boyle MP, et al. Longitudinal association
between medication adherence and lung health in people with
cystic fibrosis. J Cyst Fibros. 2011; 10(4): 259-264.


0%

16.66%

Xolair® (omalizumab)

30.3%

TOBI® (tobramycin inhalation solution)

50%

47.9%

Pulmozyme® (dornase alfa)

33.33%

12.3%

Cayston® (aztreonam lysinate for inhalation)
Prolastin® –C (alpha 1-proteinase inhibitor)

4.1%
2.2%

BY THE NUMBERS

$

5.56

PMPY Spend

0.002

0.02%

#Rx PMPY

Prevalence

$

3,344.83
Average Cost/Rx



TRANSPLANT

32.7

%

of patients are

Spend in
Medical Benefit

NONADHERENT



5%

0%

16.66%

mycophenolate

24.6%

Prograf® (tacrolimus)

11.4%

Myfortic® (mycophenolate)

50%

33.3%

tacrolimus

33.33%

6.7%

Rapamune® (sirolimus)

5.2%

BY THE NUMBERS

$

4.92

PMPY Spend

0.017

0.13%

#Rx PMPY

Prevalence

$

286.34

Average Cost/Rx



TRADITIONAL THERAPY CLASS FORECAST
The Traditional Therapy Class Forecast predicts future trend based on research
about current and past cost and utilization patterns for traditional therapy classes.
Our methodology analyzes three years of prescription data, demographics, and
changes in guidelines and medication availability.

OVERALL TRADITIONAL FORECAST

TREND

OVERALL

2013
-1.0%

2014
-1.7%

2015
-1.4%

Drivers
• Spend for traditional drugs will continue to decline year over year through at least 2015, primarily as
a result of declines in drug costs. Utilization is expected to remain relatively stable.
• dditional savings opportunities still loom on the horizon. For example, in 2013, drugs whose
A
annual sales total $14 billion will lose patent protection, including some frequently utilized
medications such as Lidoderm® (lidocaine) and Cymbalta® (duloxetine).
• ther patent expirations in 2014 and 2015 will further drive down drug costs by increasing the
O
availability of generic medications in the most highly utilized therapy classes.


DIABETES

TREND

DIABETES

2013
8.9%

2014
6.8%

2015
6.7%

Drivers
• Diagnosis and treatment of type 2 diabetes continue to increase utilization in this class, driven by
the large number of overweight and obese individuals in the U.S.
• Brand inflation of the long-acting insulins and newer drugs for treating type 2 diabetes will result in
an increase in unit cost trend.
• A new class of medications, sodium-dependent glucose cotransporter 2 (SGLT-2) inhibitors, is
expected to gain market share, as these medications are associated with weight reduction.
• Food and Drug Administration (FDA) approval of competitors to existing dipeptidyl peptidase-4
(DPP-4) inhibitors and glucagon-like peptide-1 (GLP-1) agonists and to the SGLT-2 inhibitors will
contribute to brand inflation.


TREND


2013
-6.9%

2014
-4.0%

2015
-5.3%

Drivers
• Lipitor’s® (atorvastatin) patent expiration (December 2011) and the expiration of Ranbaxy’s generic
exclusivity arrangement are primary drivers of a decrease in year-over-year cost in this therapy class.
• Tricor’s® (fenofibrate) patent expiration (November 2012) will contribute to lower costs for the class
in 2013.
• ew cholesterol guidelines scheduled for release in late 2013 are expected to increase awareness and
N
treatment. But the guidelines’ release is not expected to affect overall trend, given major cost decreases
in this therapy class.


HIGH BLOOD PRESSSURE/HEART DISEASE

TREND

HIGH BLOOD PRESSURE/HEART DISEASE

2013
-7.2%

2014
-5.9%

2015
-6.0%

Drivers
• The availability of generic medications across subclasses and the limited pipeline of new brand drugs
will contribute to decreases in unit costs.
• The angiotensin receptor blocker (ARB)-specific “patent cliff” will keep trend negative in 2013 and
2014.
• New guidelines to be released in the spring or summer of 2013 are expected to increase utilization,
which will slow the deceleration of costs.

ASTHMA

TREND

ASTHMA

2013
-7.3%

2014
0.8%

2015
1.3%

Drivers
• Generic formulations of Singulair® (montelukast) will keep trend negative in 2013.
• With barriers to interchangeable generics and direct-to-consumer advertisements played on heavy
rotation, Advair® Diskus (fluticasone propionate and salmeterol) will drive positive trend after 2013.
• Continuity of branded inhalers will contribute to positive trend, impacted by regulations banning
chlorofluorocarbons (CFC), which were used in older inhalers. The regulations not only resulted in
the market withdrawal of generic albuterol inhalers in late 2008, but also contributed to a delay in
generics to other inhalers whose patents have expired.
• New long-acting inhaled drugs for treating chronic obstructive pulmonary disease (COPD) will
compete on the market over the next few years. These once-to-twice-daily products will offer
treatment options for patients with COPD, but at a cost.


ULCER DISEASE

TREND

ULCER DISEASE

2013
-5.6%

2014
-6.4%

2015
-13.2%

Drivers
• A lack of pipeline activity, heavy genericization and over-the-counter use in this class are contributing
to the expected sharp decline in year-over-year costs.
• Patent expirations for two remaining high-market-share brands — Aciphex® (rabeprazole), whose
patent will expire in November 2013, and Nexium® (esomeprazole), whose patent will expire in May
2014 — will further decrease costs.

DEPRESSION

TREND

DEPRESSION

2013
-4.7%

2014
-8.7%

2015
-6.5%

Drivers
• The antidepressant market is expected to stabilize somewhat after the patent expiration for Lexapro®
(escitalopram), which will result in the deceleration of year-over-year cost decreases in 2013.
However, the class has many generics already, with blockbuster Cymbalta® (duloxetine), a
serotonin-noripenephrine reuptake inhibitor (SNRI), expected to lose patent protection in 2013.
• ew SNRIs such as levomilnacipran and edivoxetine are promising, but their impact will be limited
N
by existing competition in the class.

Drug Trend Report — Commercial

40

ATTENTION DISORDERS

TREND

ATTENTION DISORDERS

2013
4.4%

2014
10.0%

2015
8.6%

Drivers
• Stabilization after the 2012 shortage of generic products is contributing to the deceleration of drug
cost increases in 2013.
• Competition among generic formulations of many highly utilized medications is also expected to
dampen cost increases.
• rend is expected to accelerate in 2014 as utilization continues to increase among young and middle-age
T
adults, and the Drug Enforcement Administration enforces supply limitations of key ingredients.


TREND


2013
-7.4%

2014
-1.8%

2015
-5.7%

Drivers
• Negative trend is expected to continue in 2013, driven by a continuing wave of patent expirations
for highly utilized medications such as Zyprexa® (olanzapine) in 2011 and Geodon® (ziprasidone)
and Seroquel® (quetiapine) in 2012.
• he rate of decrease in year-over-year drug costs is expected to slow in 2014 prior to the April 2015
T
patent expiration for Abilify® (aripiprazole), the best-selling atypical antipsychotic.


PAIN

TREND

PAIN

2013
-3.3%

2014
-4.5%

2015
-4.2%

Drivers
• Increasing availability of generic formulations of some pain medications, including narcotics, is
driving the expected negative trend in the next few years, along with decreased utilization of narcotics,
which may be influenced by public and legal scrutiny of use.
• The Food and Drug Administration’s (FDA) ruling to deny generics to OxyContin® (oxycodone) is
expected to somewhat mitigate the decrease in year-over-year drug spend.

INFECTIONS

TREND

INFECTIONS

2013
-6.9%

2014
-6.8%

2015
-6.0%

Drivers
• The forecasted year-over-year decrease in costs is being driven by the availability of generic anti-infective
medications in this therapy class.
• Generics to the broad-spectrum quinolone, Avelox® (moxifloxacin), expected in March 2014, are also
likely to contribute to negative trend.
• Trend in this therapy class is also heavily influenced by the intensity of the influenza season, which
is likely to be milder in 2013-2014 than it was in 2012-2013, partly due to an expected increase
in the availability of new influenza vaccines FluMist® Quadrivalent (influenza vaccine) and Flucelvax®
(influenza virus vaccine).


SPECIALTY THERAPY CLASS FORECAST
The Specialty Therapy Class Forecast predicts future trend based on research
about current and past cost and utilization patterns for specialty therapy classes.
Our methodology analyzes three years of prescription data, demographics, and
changes in guidelines and medication availability.

OVERALL SPECIALTY FORECAST

TREND

OVERALL

2013
17.8%

2014
19.6%

2015
18.4%

Drivers
• Less than 1% of prescriptions filled in 2012 were for specialty medications, yet they accounted for 25%
of total prescription drug expenditures. By 2019 or 2020, specialty drugs are expected to represent 50%
of plan sponsors’ overall drug spend. The top three therapy classes inflammatory conditions, multiple
sclerosis and cancer are expected to account for more than 50% of that overall spend.
• At least 60% of the new drugs expected to gain approval from the Food and Drug Administration
(FDA) in 2013 alone will be specialty drugs.
• he primary driver of specialty drug spend will be a continuing increase in drug costs. Costs will rise
T
as newer, more-sophisticated therapies with price tags worth tens and hundreds of thousands of dollars
are brought to market.
• he introduction of biosimilars in key therapy classes with high-cost, highly utilized drugs has the
T
potential to alter the trajectory of specialty drug spend.



TREND


2013
25.1%

2014
17.2%

2015
17.4%

Drivers
• Double-digit trend in this therapy class is expected to continue due to general brand inflation and
competition for profits among older disease-modifying drugs because of Xeljanz® (tofacitinib), the
new oral medication indicated to treat rheumatoid arthritis.
• The absence of biosimilars on the horizon is also expected to keep costs in this therapy class high.
• tilization is expected to increase slightly as patients begin therapy with these drugs after expansion of
U
indications and as physicians become increasingly comfortable prescribing specialty medications to
treat conditions such as rheumatoid arthritis, Crohn’s disease and psoriasis.

MULTIPLE SCLEROSIS

TREND

MULTIPLE SCLEROSIS

2013
19.8%

2014
18.5%

2015
16.8%

Drivers
• Continued manufacturer increases in drug prices and the approval of additional therapies, including
the new oral agent, Tecfidera® (dimethyl fumarate), are expected to drive double-digit growth in drug
spend for multiple sclerosis (MS) medications in the next few years.
• Because the average onset of disease tends to be in younger patients, new utilization is expected to
slow as the population ages. However, the lack of new utilizers is not expected to drastically alter the
trajectory of year-over-year cost increases.


44

CANCER

TREND

CANCER

2013
21.3%

2014
20.9%

2015
21.0%

Drivers
• The Food and Drug Administration (FDA) is increasingly approving new, highly targeted therapies
that treat cancer based on a patient’s specific genetic or proteomic profiles. These drugs are often
associated with a more expensive research and development process, which may lead to higher price
tags in this therapy class.
• High inflation rates for older medications whose manufacturers may be trying to protect profit
margins may also contribute to double-digit increases in year-over-year drug costs.
• he stacking of therapies is more common as cancer survivorship increases and patients add
T
additional therapies over time.

HIV

TREND

HIV

2013
9.2%

2014
9.6%

2015
9.4%

Drivers
• Cost increases are expected to mount due to the shift from multiple, older generic regimens to
single-pill branded combination therapies with steep price tags.


HEPATITIS C

TREND

HEPATITIS C

2013
33.0%

2014
58.5%

2015
168.4%

Drivers
• Although the increase in new hepatitis C patients will continue to decelerate in 2013, new patients
are still using protease inhibitors Incivek® (telaprevir) and Victrelis® (boceprevir), which are more
expensive than other medications in the class.
• New interferon-free regimens are expected to gain Food and Drug Administration (FDA) approval
beginning in late 2013, which will drive dramatic cost increases. Costs are expected to be especially
high beginning in late 2014, when an all-oral regimen is expected to be approved for patients with
genotype 1 hepatitis C, the most common type.
• n increase in the number of newly diagnosed patients resulting from the issuance of new screening
A
guidelines, along with a secondary warehousing of patients waiting to initiate therapy with new
medications, is expected to result in a steadily rising rate of new users.

GROWTH DEFICIENCY

TREND

GROWTH DEFICIENCY

2013
6.2%

2014
5.9%

2015
6.5%

Drivers
• With limited novel or biosimilar growth hormone therapies in the pipeline, the increase in year-overyear drug costs is expected to contribute to stable increases in PMPY spend in the next few years.


ANTICOAGULANTS

TREND

ANTICOAGULANTS

2013
-0.3%

2014
-0.2%

2015
0.0%

Drivers
• Utilization and costs in the class are expected to decline due to the future introduction of oral
anticoagulants that will be considered traditional medications rather than specialty medications.
• The decline in costs is expected to be tempered in 2014 and 2015 by flat, rather than decreasing, costs
for generic Lovenox® (enoxaparin). Because there are few competitors, slight brand inflation may occur.


TREND


2013
11.0%

2014
11.1%

2015
10.5%

Drivers
• Two new oral therapies — riociguat and Opsumit™ (macitentan) — that are expected to be approved
in the near future will contribute to increased costs and utilization in this class.
• The launch of generics to Revatio® (sildenafil) in late 2012 is expected to mitigate trend.
• enerics to Tracleer® (bosentan) are expected to be approved in late 2015; their effect on trend
G
won’t be clear until 2016 and beyond.



TREND


2013
24.8%

2014
29.5%

2015
27.9%

Drivers
• High-cost brands including Kalydeco® (ivacaftor), a treatment for some patients with cystic fibrosis
(CF), will continue to drive increased spend in this class.
• Other new drugs to treat CF, including the recently approved TOBI® Podhaler (tobramycin inhalation
powder), also will impact this class. Lumacaftor, an oral, pipeline drug to treat the underlying
disease in as many as half of CF patients, is expected to significantly increase utilization and drug
costs in this class.
• Esbriet® (pirfenidone), which may be the first drug approved to treat idiopathic pulmonary fibrosis,
may impact trend in 2014.

TRANSPLANT

TREND

TRANSPLANT

2013
-2.2%

2014
1.0%

2015
-1.2%

Drivers
• Drug costs are expected to be relatively stable, driven by the availability of generics in this class.
• No new brand or generic drugs that would impact this class are on the horizon.


48

MEDICARE FEATURE ARTICLES
Timely, topical and in-depth analysis of issues particularly relevant to Medicare
Advantage Part D (MAPD) Plans, Employer Group Waiver Plans (EGWPs) and
standalone Prescription Drug Plans (PDPs).

HOW PRIOR AUTHORIZATION CAN HELP MEMBERS AND BOOST STAR RATINGS

High-risk medications (HRM), also known as high-alert or high-hazard
medications, are drugs that have an increased risk of harmful side effects
even when used as indicated and for which a safer alternative is available.
Controlling their usage will both increase patient safety and boost star ratings.
The five-star rating system from the Centers for Medicare Medicaid Services
(CMS) includes a category for Patient Safety and Accuracy of Drug Pricing.
A specific measure, known as D14, rates Medicare Part D Prescription Drug
Plans (PDPs) and Medicare Advantage Plans (MAPDs) based on the percentage
of plan members age 65 and older who fill prescriptions for certain high-risk
medications even though safer drug options are available.1
The HRM rate measures the percentage of plan members, as a subset of
all plan members, who receive at least two fills for a high-risk prescription
medication. It is incorporated as part of a plan’s overall star rating, which
can range from 1 to 5 (with 5 being the highest).
CMS treats the high-risk medication measure as an intermediate outcome measure, weighting it three
times more than some other measures, including process measures such as enrollment timeliness. Thus,
the HRM measure is a high-impact performance area for Medicare Part D plan sponsors. In practice, the
HRM star rating is aggregated, along with the star ratings for other outcome and process measures, into
a total star rating for a given MAPD or PDP. According to the 2013 CMS technical notes, the national
numeric average HRM rates in 2011 were 7.8% for MAPDs and 8.8% for PDPs, which translate to an
average star rating of 3.1 out of 5 for both plan types.1
Drug Trend Report — Medicare 50

Patient Safety through Prior Authorization
Express Scripts designed its High-Risk Medication Prior Authorization (HRMPA) program in 2011 to
drive patient safety by monitoring the real-time dispensing of CMS-classified high-risk medications.
The HRMPA program supports plan sponsors’ prior authorization (PA) and medical exception initiatives,
offers review services 24 hours a day throughout the year, and gives physicians and pharmacists easy
access to PA information.
In 2011, the original HRMPA program monitored high-risk medications in two therapeutic classes: skeletal
muscle relaxants and first-generation (sedating) antihistamines. Since then, the Express Scripts program
has expanded to align with CMS’s updated HRM list, including PA and step therapy implementations for
barbiturates and benzodiazepines. Additional HRMs are being evaluated for inclusion in the future. The
figure below shows how our HRMPA program promotes the use of safer alternative prescription drugs at
the point of service.


Express Scripts researched the effect of our HRMPA program on the use of high-risk medications among
our Medicare plan members. The study involved more than 65 health plan contracts representing more
than 2.2 million Medicare lives. Clients with CMS contracts were grouped into two categories based on
whether they used the Express Scripts HRMPA program. Similar to the methodology used by CMS in
measuring the HRM rate, researchers calculated the percentage of Medicare Part D beneficiaries who
received two or more prescription fills for a drug with a high risk of serious side effects in the elderly
in 2011. Using an unadjusted test of association (two-sample t-test), the study analyzed whether the
numerical averages between the two groups differed on the percentage of high-risk medications that
the plan members received.
Results showed that across MAPD and PDP plans, HRM prescriptions were received by 7.4% of members
in contracts that did not have the HRMPA program in place, compared to an HRM rate of only 5.5% in
contracts that did have the Express Scripts HRMPA program. (See table below.) Notably, Express Scripts
MAPD and PDP plans overall — including those without the HRMPA program — dispensed lower percentages
of high-risk medications to Medicare beneficiaries than the national averages for their counterpart plans.

On average, beneficiaries whose plan sponsors implemented the HRMPA program had an HRM rate
which was 1.9 percentage points less than that of beneficiaries whose plan sponsors did not implement
HRMPA (P0.05). For MAPDs, 5.4% of plan members with HRMPA received high-risk medications
compared to 7.1% of those without the program — a significant difference of 1.7 percentage points
(P0.05). For PDPs, the difference was 3.1 percentage points, with only 6.0% of plan members with
HRMPA receiving high-risk medications compared to 9.1% of those without an HRMPA program.
Healthier Outcomes and Higher Star Ratings
The evidence clearly shows that plan sponsors can achieve healthier outcomes — and a higher CMS
star rating — by strategically using advanced clinical pharmacy benefit management solutions to more
effectively monitor and control the high-risk medications that members receive.

Footnotes
1. enters for Medicare Medicaid Services. Medicare health drug plan quality and performance ratings 2013 Part C
C
Part D technical notes. Updated April 4, 2013. Available at: http://www.cms.gov/Medicare/Prescription-Drug-Coverage/
PrescriptionDrugCovGenIn/PerformanceData.html. Accessed July 15, 2013.


TOTAL TREND
The Medicare Total Trend measures the rate of change in total spend driven by
utilization and unit cost for the population covered by Medicare Advantage Part D
(MAPD) Plans, Employer Group Waiver Plans (EGWPs) and standalone Prescription
Drug Plans (PDPs).

COMPONENTS OF MEDICARE TREND, 2012
TREND
PMPY SPEND
Traditional
Specialty
TOTAL OVERALL

UTILIZATION

UNIT COST

TOTAL

$1,908.70

1.8%

-2.6%

-0.7%

$353.62

-2.7%

26.8%

24.1%

$2,262.32

1.8%

0.7%

2.5%

*January–December 2012 compared to same period in 2011

Key Insights
• MPY spend for Medicare was more than double that of the Commercial book of business, as Medicare
P
beneficiaries use more medications overall. However, total trend was slightly lower, driven by lower
costs for traditional drugs, which represent a larger proportion of total spend for Medicare compared
to the Commercial book of business.
• or traditional medications, annual utilization increased 1.8%, offset by an annual cost decrease of
F
2.6%, resulting in negative total traditional trend. However, a 26.8% increase in costs for specialty
medications led to positive annual specialty trend.


COMPONENTS OF MEDICARE TREND, MAPD
TREND
PMPY SPEND
Traditional
Specialty
TOTAL OVERALL

UTILIZATION

UNIT COST

TOTAL

$2,018.80

2.8%

-1.0%

1.9%

$357.44

-2.1%

27.9%

25.8%

$2,376.25

2.8%

2.1%

4.9%

January – December 2012 compared to same period in 2011

Key Insights
• PMPY spend and total trend were higher for MAPD plans than for EGWPs or PDPs.

COMPONENTS OF MEDICARE TREND, EGWP
TREND
PMPY SPEND
Traditional
Specialty
TOTAL OVERALL

UTILIZATION

UNIT COST

TOTAL

$1,826.41

0.7%

-3.3%

-2.6%

$358.07

-5.9%

25.8%

20.0%

$2,184.48

0.7%

-0.2%

0.5%


Key Insights
• PMPY spend and total trend were lower for EGWPs than for MAPDs, but higher than MPY spend
P
and total trend for PDPs.

COMPONENTS OF MEDICARE TREND, PDP
TREND
PMPY SPEND
Traditional
Specialty
TOTAL OVERALL

UTILIZATION

UNIT COST

TOTAL

$1,706.76

0.2%

-6.7%

-6.5%

$340.65

-3.3%

26.6%

23.3%

$2,047.40

0.1%

-2.8%

-2.6%


Key Insights
• DPs had a negative overall trend, driven by a decrease in cost for traditional medications, many of
P
which are newly available as generics. Total trend for PDPs was lower than that of other Medicare plans.
Drug Trend Report — Medicare

54

The Medicare Traditional Therapy Class Trend section highlights key traditional
Medicare Advantage Part D (MAPD) Plans, Employer Group Waiver Plans (EGWPs)
and standalone Prescription Drug Plans (PDPs).

Components of Trend for the Top 10 Medicare
TREND
THERAPY CLASS

PMPY SPEND

UTILIZATION

UNIT COST

TOTAL

Diabetes

$278.72

4.5%

10.6%

15.2%

High Blood Cholesterol

$209.58

1.5%

-8.2%

-6.7%


$194.28

1.7%

-2.9%

-1.2%


$144.58

2.4%

-19.3%

-16.9%

Asthma

$122.56

3.8%

5.5%

9.3%

Ulcer Disease

$95.19

7.7%

-12.1%

-4.4%

Blood Modifying

$78.67

-2.8%

-33.8%

-36.6%

Pain

$77.35

4.1%

-2.8%

1.3%

Depression

$70.66

4.7%

0.2%

4.9%

Urinary Disorders

$64.29

1.3%

-7.4%

-6.1%

$572.81

0.2%

6.3%

6.5%

$1,908.70

1.8%

-2.6%

-0.7%

Other
TOTAL TRADITIONAL

Key Insights
• iabetes medications had the highest overall trend, driven primarily by increased costs. Although
D
changes in costs reflect the impact of new drugs such as Tradjenta® (linagliptin), increased prices for
insulin drugs drove much of the change.
• osts for medications used to treat mental/neurological disorders have declined 19.3%, driven by patent
C
expirations for Seroquel® (quetiapine) and Geodon® (ziprasidone) in 2012, and continued utilization of
generic olanzapine and donepezil in place of brands Zyprexa® and Aricept®.
• tilization of pain medications increased 4.1% in 2012 compared to 2011, but unit costs dropped
U
by 2.8%, leading to a relatively flat overall trend. Recent data suggest that growth in pain medication
prescriptions for elderly patients has outpaced that of other age groups, in part due to pharmaceutical

manufacturer influence on doctors and pain advocacy groups.1 Although narcotic pain medications
have been the subject of scrutiny because of prescription drug abuse, their use in elderly patients
may be more accepted because of the perception of clinical need.
• 33.8% drop in unit costs led to a significant negative total trend for the blood modifying class.
A
This was almost exclusively driven by the May 2012 expiration of the blockbuster brand drug Plavix®
(clopidogrel), which had captured 85% of market share in the class before the patent expired. The
average cost per prescription for generic clopidogrel was 29.9% of the average cost for brand Plavix.

Footnotes
1. auber J, Gabler E. Narcotic painkiller use booming among elderly. Medpage Today. May 30, 2012. Available at:
F
http://www.medpagetoday.com/Geriatrics/PainManagement/32967. Accessed February 3, 2013.


The Medicare Specialty Therapy Class Trend section highlights key specialty therapy
classes and explains factors driving trend for the population covered by Medicare
Advantage Part D Plans (MAPD), Employer Group Waiver Plans (EGWPs) and
standalone Prescription Drug Plans (PDPs).

Components of Trend for the Top 10 Medicare
TREND
THERAPY CLASS

PMPY SPEND

UTILIZATION

UNIT COST

TOTAL

$108.39

11.8%

21.1%

32.8%

Multiple Sclerosis

$51.68

8.5%

18.2%

26.7%


$47.69

7.4%

13.0%

20.4%

HIV

$30.31

1.6%

9.1%

10.7%


$25.58

9.8%

4.0%

13.8%

Anticoagulants

$16.57

1.0%

3.7%

4.7%

Hepatitis C

$10.83

63.5%

46.9%

110.4%

Immune Deficiency

$10.63

34.6%

-0.8%

33.8%

Blood Cell Deficiency

$10.43

-8.2%

8.0%

-0.2%

$9.52

9.1%

2.9%

12.0%

$32.00

-28.1%

55.2%

27.1%

$353.62

-2.7%

26.8%

24.1%

Cancer

Osteoporosis
Other
TOTAL SPECIALTY

Key Insights
• tilization of cancer medications increased 11.8% in comparison to 2011, contributing to the overall
U
32.8% increase in PMPY spend. Much of the increase was driven by new medications such as
Afinitor® (everolimus) and Zelboraf® (vemurafenib), which provide second- and third-line treatment
options for patients with certain treatment-refractory cancers. However, increased utilization was also
seen for Avastin® (bevacizumab) and fluorouracil, both of which might be prescribed off-label to treat
non-cancer conditions, such as macular degeneration and actinic keratoses (“sun spots”), which
mainly afflict elderly patients.1,2
• 63.5% increase in utilization of medications used to treat hepatitis C was coupled with a 46.9%
A
increase in unit costs, resulting in a triple-digit total trend for the class. The increases primarily

resulted from two fairly new hepatitis C drugs, Incivek® (telaprevir) and Victrelis® (boceprevir), approved
in mid-2011. The drugs are the first new hepatitis C treatments in more than a decade and the first
oral antivirals to treat hepatitis C; however, both must be used in combination with older drugs.
Utilization is likely to be especially high among patients born between 1945 and 1965; not only are
hepatitis C virus infection rates more prevalent in this age group,3 but physicians may have been
reluctant to prescribe previous therapies for older patients because of increased comorbidities or the
fear of adverse treatment events.4
• n 8.2% decrease in utilization of medications used to treat blood cell deficiencies in Medicare
A
beneficiaries led to a negative total trend for the therapy class. The decrease was driven by changes
in utilization of erythropoiesis-stimulating agents (ESAs) such as Procrit® (epoetin alfa) and Aranesp®
(darbepoetin alfa), likely in response to recent FDA recommendations for more conservative dosing of
these drugs in some patients. Several post-marketing studies found that ESAs are associated with an
increased risk of cardiovascular events such as stroke, thrombosis and even death.5 In response, the
Centers for Medicare and Medicaid Services altered coverage rules.6
• tilization of medications used to treat immune deficiencies increased 34.6% in 2012, leading to a
U
33.8% total trend. Utilization increases are likely related to expanded FDA-approved indications for
Gammagard® Liquid (immune globulin),7 the most commonly used immune deficiency medication
among Medicare beneficiaries, and to an increase in off-label use of immunoglobulin products by the
aging population.8,9

Footnotes
1. augh TH. Avastin cheaper than Lucentis for AMD, but has higher risks. The Los Angeles Times. June 20, 2012.
M
Available at: http://www.articles.latimes.com/2012/jun/20/science/la-sci-sn-lucentis-avastin-20120620. Accessed
February 1, 2013.
2. achs DL, Kang S, Hammerberg C, et al. Topical fluorouracil for actinic keratoses and photoaging: a clinical and
S
molecular analysis. Arch Dermatol. 2009; 145(5): 659-666. .
3. mith BD, Morgan RL, Beckett GA, et al. Recommendations for the identification of chronic hepatitis C virus infection
S
among persons born during 1945-1965. MMWR. August 17, 2012; 61(RR04): 1-18.
4. indikoglu AL, Miller RR. Hepatitis C in the elderly: epidemiology, natural history and treatment. Clin Gastroenterol
M
Hepatol. 2009; 7(2): 128-134.
5. S Food and Drug Administration. Press Announcements - FDA modifies dosing recommendations for erythropoiesisU
stimulating agents. June 24, 2011. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/
ucm260670.htm. Accessed February 1, 2013.
6. enters for Medicare Medicaid Services. Decision memo for erythropoiesis stimulating agents (ESAs) for non-renal
C
disease indications. Available at: http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAI
d=203ver=12NcaName=Erythropoiesis+Stimulating+Agents+bc=BEAAAAAAIAAA. Accessed February 4, 2013.
7. S Food and Drug Administration. Vaccines, Blood Biologics – Gammagard Liquid. June 22, 2012. Available at:
U
http://www.fda.gov/BiologicsBloodVaccines/BloodBloodProducts/ApprovedProducts/LicensedProductsBLAs/
FractionatedPlasmaProducts/ucm089392.htm. Accessed February 8, 2013.
8. lobal immunoglobulin products market driven by the increase in the aging population. Companies and Markets.com.
G
Available at: http://www.companiesandmarkets.com/News/Healthcare-and-Medical/Global-immunoglobulinproducts-market-driven-by-the-increase-in-the-aging-population/NI6382. Accessed February 8, 2013.
9. atz U, Shoenfeld Y, Zandman-Goddard G. Update on intravenous immunoglobulins (IVIg) mechanisms of action and
K
off-label use in autoimmune diseases. Curr Pharm Des. 2011; 17(29): 3166-3175.

Drug Trend Report — Medicare

58

MEDICAID FEATURE ARTICLES
Timely, topical and in-depth analysis of issues particularly relevant to the
population covered by Medicaid.

THE OVERRELIANCE ON RESCUE MEDICATIONS FOR MEDICAID ASTHMA PATIENTS

Two general types of medications are used to treat asthma. Some are classified as controller medications,
which aid in preventing asthma exacerbations (worsening of symptoms). Controller medications should
be taken daily on a long-term basis to reduce airway inflammation, decrease mucus production and
desensitize the lungs to environmental triggers.1,2 The second main type of asthma medications is rescue
medications, which are used on an as-needed basis for acute symptom relief. Rescue medications
work by helping to relax airways.3 In general, rescue medications should be used judiciously, and using
rescue medications to treat acute asthma symptoms more than two days per week likely indicates the
need for controller medications.2

Asthma and Medicaid
Among Medicaid beneficiaries for whom Express Scripts manages pharmacy benefits, asthma is the most
prevalent and costly condition at the per-member-per-year (PMPY) level. In 2012, 15.1% of Medicaid
beneficiaries used asthma medications at a PMPY cost of $59.47, which represented a 6.2% increase
in PMPY spend between 2011 and 2012. Spend in the class increased despite the patent expiration of
the blockbuster drug Singulair® (montelukast), which prior to losing patent protection on August 3, 2012,
held more than 10% of the Medicaid asthma therapy class market share.4
In addition to being expensive, asthma and its treatments are especially important for Medicaid because
of the complex relationship between asthma and income — further confounded by a possible contribution of
urban environments to asthma exacerbations. Asthma disproportionately impacts populations with low
annual household incomes,5 and may be more prevalent in urban environments. Both groups include
many receiving healthcare benefits through Medicaid. Some studies suggest that Medicaid patients

Drug Trend Report — Medicaid 60

with asthma have more attacks and use more healthcare resources than similar patients with private
insurance or even no insurance.6,7
A recent Express Scripts examination of asthma medication utilization among Medicaid beneficiaries
sheds light on some of the utilization drivers in the class. Specifically, Express Scripts researchers
compared utilization of rescue and controller medications over time and across different subpopulations
of gender, urbanicity and age. Our goals were to determine what kinds of medications were used by
Medicaid beneficiaries and whether utilization patterns changed between 2011 and 2012.

Utilization of Controller and Rescue Medications
Among 315,600 Medicaid beneficiaries age 0 to 64 who were using any type of asthma medication in
2012, a greater proportion of beneficiaries were using rescue medications than controller medications.
In our study, 90% of beneficiaries filled at least one prescription for a rescue medication, only 42.4%
filled a prescription for a controller medication and about one-third used both rescue medications
and controller medications. Notably, 55.7% were using only rescue medications, implying inadequate
asthma control, which often leads to increased medical resource utilization8 (data not shown).
Patterns of controller and rescue medication use by gender and urbanicity are shown in the table
below. Little difference was seen between males and females using rescue medications (89.8% vs.
90.2%, respectively), but a slightly higher percentage of males used controller medications (43.9% vs.
41.2%). A higher percentage of nonurban than urban patients had claims for controller medications
(45.8% vs. 42.3%), but a greater percentage of urban patients than nonurban patients filled prescriptions
for rescue medications (90.2% vs. 84.7%).


Utilization of controller and rescue medications by age is shown in the figure below. With regard to age,
controller medication use was higher for children age 5 to 9, and for 10 to 14 year olds, and then declined
in young adults before increasing again among older beneficiaries. At the same time, rescue medication use
experienced only a slight increase among older teenagers and young adults before declining for beneficiaries
older than age 30. The increase among older beneficiaries partially reflects the increased prevalence of
chronic obstructive pulmonary disease (COPD), as many asthma controller medications are also used
to treat COPD, a progressive condition that generally does not produce symptoms in patients younger
than age 40.


The study also examined utilization trend — the year-to-year change in the total days’ supply of
medication. (See table below.) Between 2011 and 2012, the amount of rescue medications being
used increased at a faster rate (2.0%) than did the amount of controller medications (0.8%). Male
beneficiaries had larger increases in utilization than females. There was also a slight gap in rescue
utilization trend between urban and nonurban populations.

Drug Trend Report — Medicaid

63

Breaking down utilization by age, rescue medication utilization increased the most (6.2%) among
beneficiaries age 25 to 29. (See figure below.) Utilization of rescue medications increased 5.7% in patients
age 50 to 54. The change in controller medication utilization was also high in beneficiaries age 50 to 54
(5.6%), topped only by a 6.3% increase for those age 55 to 59. Increases in asthma drug utilization among
older Medicaid beneficiaries may reflect increased COPD diagnoses in older patients.8 Utilization of
controller medications decreased the most (-4.9%) among beneficiaries age 20 to 24, whereas rescue
medication utilization decreased the most (-9.3%) among the youngest Medicaid beneficiaries, those
age 0 to 4.

Summary
Across all Medicaid subpopulations in our study, the most commonly used asthma medications were
rescue medications, as opposed to controller medications. Additionally, utilization trend increased at a
faster rate for rescue medications than for controller medications. Both findings are counter to asthma
treatment guidelines, which recommend daily, long-term use of controller medications to prevent
asthma exacerbations. Frequent use of rescue medications suggests poor asthma management, resulting
in avoidable asthma exacerbations and potentially increasing overall healthcare expense.
Understanding basic utilization patterns among Medicaid beneficiaries with asthma is an important
step in identifying additional opportunities for further education and intervention. More comprehensive
explorations of utilization patterns are needed to reveal more detailed information about the true extent
of controller medication underutilization and rescue medication overutilization. Just as important,
determining and addressing the reasons for poor utilization help Express Scripts and Medicaid plan
sponsors enable patients to make better decisions that ultimately lead to healthier outcomes.

64

Footnotes
1. onas DE, Wines RCM, DelMonte M, et al. Drug class review: controller medications for asthma: final update 1 report
J
[Internet]. Portland, Ore.: Oregon Health Science University; 2011. Available at: http://www.ncbi.nlm.nih.gov/books/
NBK56695/. Accessed July 5, 2013.
2. ational Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and ManageN
ment of Asthma (EPR-3). Bethesda, Md.: National Institutes of Health. 2007. Available at: http://www.nhlbi.nih.gov/
guidelines/asthma/asthgdln.htm. Accessed July 5, 2013.
3. .S. National Library of Medicine. Asthma: quick-relief drugs. March 22, 2013. Available at: http://www.nlm.nih.gov/
U
medlineplus/ency/patientinstructions/000008.htm. Accessed July 5, 2013.
4. xpress Scripts. 2011 Drug Trend Report. April 2012. Available at: http://digital.turn-page.com/i/70797. Accessed
E
July 5, 2013.
5. ligne CA, Auinger P, Byrd RS, Weitzman M. Risk factors for pediatric asthma: contributions of poverty, race, and urban
A
residence. Am J Respir Crit Care Med. 2000;162(3 Pt 1):873–877.
6. inkelstein JA, Barton MB, Donahue JG, et al. Comparing asthma care for Medicaid and non-Medicaid children in a
F
health maintenance organization. Arch Pediatr Adolesc Med. 2000;154(6):563–568.
7. pter AJ, Reisine ST, Kennedy DG, Cromley EK, Keener J, ZuWallack RL. Demographic predictors of asthma treatment
A
site: outpatient, inpatient or emergency department. Ann Allergy Asthma Immunol. 1997;79(4):353–361.
8. ershon AS, Wang C, Wilton AS, Raut R, To T. Trends in chronic obstructive pulmonary disease prevalence, incidence and
G
mortality in Ontario, Canada, 1996 to 2007: a population based study. Arch Intern Med. 2010;170(6):560–565.


TOTAL TREND
The Medicaid Total Trend measures the rate of change in total spend driven by
utilization and unit cost for the population covered by Medicaid.

COMPONENTS OF MEDICAID TREND, 2012
TREND
PMPY SPEND

UTILIZATION

UNIT COST

TOTAL

Traditional

$337.26

3.8%

1.5%

5.3%

Specialty

$113.32

-0.8%

16.7%

15.9%

TOTAL OVERALL

$450.58

3.8%

4.0%

7.8%

January–December 2012 compared to same period in 2011

Key Insights
• otal overall Medicaid PMPY spend increased 7.8% in 2012, driven nearly equally by increases in
T
utilization and drug costs. Although utilization increased significantly for traditional medications, it
decreased for specialty medications. Cost increases for specialty medications far outpaced those for
traditional drugs (16.7% vs. 1.5%).
• any of the top specialty therapy classes in 2012, such as those used to treat HIV, inflammatory
M
conditions and multiple sclerosis, had double-digit cost increases, leading to an overall annual trend
of 15.9%. However, overall annual specialty trend for Medicaid was lower than that for both the
Commercial and Medicare populations. This may be related to the kinds of specialty medications
used by Medicaid beneficiaries, who tend to be younger than beneficiaries in other populations.


COMPONENTS OF TREND, MEDICAID AGES 0-19, 2012
TREND
PMPY SPEND
Traditional
Specialty
TOTAL OVERALL

UTILIZATION

UNIT COST

TOTAL

$162.35

3.5%

-0.5%

3.0%

$39.04

1.0%

6.4%

7.4%

$201.39

3.4%

0.3%

3.8%


Key Insights
• otal overall trend in the youngest Medicaid beneficiaries was lower than the total overall trend
T
across all Medicaid beneficiaries (3.8% vs. 7.8%). This was driven by relatively flat utilization of
specialty medications and slightly lower unit costs in 2012 compared to 2011.

TREND
PMPY SPEND

UTILIZATION

UNIT COST

TOTAL

Traditional

$336.90

10.4%

2.5%

13.0%

Specialty

$123.33

9.4%

13.5%

23.0%

TOTAL OVERALL

$460.23

10.4%

5.1%

15.5%


Key Insights
• otal trend for beneficiaries ages 20 to 34 was 15.5%, driven by increased utilization of traditional
T
medications and increases in both utilization and costs for specialty medications.


TREND
PMPY SPEND

UTILIZATION

UNIT COST

TOTAL

Traditional

$930.56

12.8%

2.2%

15.0%

Specialty

$364.36

7.7%

22.5%

30.2%

$1,294.93

12.8%

6.1%

18.9%

TOTAL OVERALL


Key Insights
• MPY spend and total trend were higher in Medicaid beneficiaries ages 35 to 64 than in other age
P
groups. Spend increased 18.9%, driven by growth in utilization for both traditional and specialty
medications, and a 22.5% increase in costs for specialty medications. Specialty medications accounted
for a larger proportion of total PMPY spend than in other age groups.

COMPONENTS OF TREND, MEDICAID AGES 65+, 2012
TREND
PMPY SPEND
Traditional
Specialty
TOTAL OVERALL

UTILIZATION

UNIT COST

TOTAL

$378.42

2.4%

-5.4%

-3.0%

$60.54

-14.7%

36.3%

21.6%

$438.96

2.3%

-2.5%

-0.2%


Key Insights
• mong beneficiaries ages 65 and older, total trend decreased by 0.2%, driven by decreased utilization
A
of specialty medications and lower costs for traditional medications.


68

The Medicaid Traditional Therapy Class Trend section highlights key traditional
therapy classes and explains factors driving trend for the population covered
by Medicaid.

Components of Trend for the Top 10 Medicaid
TREND
THERAPY CLASS

PMPY SPEND

UTILIZATION

UNIT COST

TOTAL

Asthma

$59.47

6.2%

0.0%

6.2%

Diabetes

$42.53

0.9%

10.5%

11.4%

Pain

$26.75

2.3%

-5.6%

-3.2%


$21.12

10.6%

-13.8%

-3.2%

Infections

$20.27

-1.5%

-4.2%

-5.7%

Attention Disorders

$17.41

12.3%

4.1%

16.4%

Seizures

$14.18

6.7%

-3.1%

3.6%


$10.00

0.3%

0.9%

1.2%

Allergies

$8.96

12.8%

-7.5%

5.4%

Chemical Dependence

$8.38

15.4%

8.9%

24.3%

Other

$108.19

3.6%

3.1%

6.8%

TOTAL TRADITIONAL

$337.26

3.8%

1.5%

5.3%

Key Insights
• sthma medications had the highest PMPY spend in the Medicaid population. Total spend increased
A
6.2% compared to 2011, driven by increased utilization. The patent for one of the most utilized
drugs in this class, Singulair® (montelukast sodium), expired in August 2012. Generic montelukast,
which was not protected under a generic exclusivity arrangement, immediately gained market share,
which helped keep unit costs flat in the class.
• eclines in both utilization and unit costs for medications used to treat infections, primarily among
D
generic antibiotics such as amoxicillin, azithromycin and levofloxacin, led to a 5.7% decline in total
spend. Utilization changes likely reflect the mild 2011-2012 flu season; because the influenza
virus and bacterial respiratory infections have similar symptoms, flu often is treated mistakenly with

antibiotics. Decreased antibiotic use may have been even more pronounced if the 2012-2013 flu
season had not been so early, severe and widespread.
• otal spend for medications used to treat attention disorders increased 16.4%, impacted primarily
T
by a 12.3% increase in utilization. While some evidence suggests that utilization of attention disorders
medications may be increasing among adults,1 some of the increase in utilization among Medicaid
beneficiaries specifically may come from increased prescribing to low-income children in an effort to
improve school performance and grades.2
• he rise in the number of Americans seeking treatment for drug and alcohol abuse3 resulted in
T
increased use of medications used to manage chemical dependence, such as Campral® (acamprosate),
Suboxone® (buprenorphine, naloxone) and disulfiram. Utilization of these medications in 2012
increased 15.4% over 2011 utilization, and unit costs rose 8.9%, leading to the highest total trend
among traditional medications.

Footnotes
1. oyer CS. Challenges of adult ADHD. Amednews.com August 27, 2012. Available at: http://www.ama-assn.org/
M
amednews/2012/08/27/hlsa0827.htm. Accessed February 3, 2013. .
2. chwartz A. Attention disorder or not, pills to help in school. The New York Times. October 9, 2012. Available at:
S
http://www.nytimes.com/2012/10/09/health/attention-disorder-or-not-children-prescribed-pills-to-help-in-school.
html?hp_r=1. Accessed February 6, 2013.
3. rank JW, Ayanian JZ, Linder HA. Management of substance use disorders in ambulatory care in the United States,
F
2001-2009. Arch Intern Med. 2012; 172(22): 1759-1760.


The Medicaid Specialty Therapy Class Trend section highlights key specialty
therapy classes and explains factors driving trend for the population covered
by Medicaid.

Components of Trend for the Top 10 Medicaid
TREND
THERAPY CLASS

PMPY SPEND

UTILIZATION

HIV

$23.40

-7.3%

5.2%

-2.1%

Hepatitis C

$12.49

-1.6%

33.5%

31.9%


$10.98

12.8%

14.4%

27.2%

Cancer

$10.42

5.3%

16.9%

22.2%

Hemophilia

$8.69

0.0%

2.2%

2.2%

Multiple Sclerosis

$8.09

1.8%

16.1%

17.9%


$6.64

17.6%

17.8%

35.4%

Growth Deficiency

$6.38

13.3%

10.4%

23.7%

Respiratory Syncytial Virus Prevention

$4.52

2.3%

12.6%

14.9%

Respiratory Conditions

$3.93

12.5%

18.3%

30.8%

$17.77

2.5%

17.3%

19.8%

$113.32

-0.8%

16.7%

15.9%

Other
TOTAL SPECIALTY

UNIT COST

TOTAL

Key Insights
• tilization of HIV medications declined 7.3%, while unit costs increased 5.2%. However, declines
U
in utilization actually reflect the changes in the number of individual prescriptions as patients move
from daily regimens of multiple individual medications such as Sustiva® (efavirenz) and Emtriva®
(emtricitabine) to combination drugs such as Atripla® (efavirenz, tenofovir, emtricitabine) and Truvada®
(tenofovir, emtricitabine). Although the multi-drug combination products are more expensive than
single-pill versions, some of which are available generically, taking fewer pills per day is associated
with increased adherence in this therapy class.1
• nit costs for medications indicated to treat hepatitis C virus increased 33.5% in 2012, driven by
U
two novel oral drugs, Incivek® (telaprevir) and Victrelis® (boceprevir), approved in mid-2011. However,

utilization was negative in the Medicaid population, as fewer new patients initiated therapy on the
new medications.
• otal trend for pulmonary hypertension (PAH) medications was 35.4% in 2012, driven by increases
T
in both utilization and cost. The utilization of PAH drugs in the pediatric population may be related
to increased awareness of the condition in recent years. However, a recent Food and Drug Administration
(FDA) warning against the use of Revatio® (sildenafil) for pediatric PAH patients2 may have shifted
utilization to more-expensive drugs such as Remodulin® (treprostinil) and Letairis® (ambrisentan).
• lthough utilization of medications that treat respiratory conditions increased 12.5%, the 30.8%
A
total trend was also driven by an 18.3% increase in unit costs. New medications in this class such
as Kalydeco® (ivacaftor), which costs almost $300,000 per patient per year,3 offer new promise to
some patients with rare conditions like cystic fibrosis by treating the underlying cause of disease
rather than the symptoms.

Footnotes
1. iroldi M, Zaccarelli M, Bisi L, et al. One-pill once-a-day HAART: a simplification strategy that improves adherence and
A
quality of life of HIV-infected subjects. Patient Prefer Adherence. 2010; 4: 115-125.
2. S Food and Drug Administration. FDA Drug safety communication: FDA recommends against use of Revatio®
U
(sildenafil) in children with pulmonary hypertension. August 30, 2012. Available at: http://www.fda.gov/Drugs/
DrugSafety/ucm317123.htm. Accessed February 1, 2013.
3. dney A. Vertex wins approval for drug to treat mutation linked to cystic fibrosis. January 31, 2012. Bloomberg.
E
Available at: http://www.bloomberg.com/news/2012-01-31/fda-approves-vertex-s-kalydeco-for-cystic-fibrosis.html.
Accessed February 8, 2013.


TREND DRIVERS

DrugTrendReport.com

PHARMACY RELATED WASTE
Since 2010, Express Scripts has employed a rigorous, scientific approach to the
study of pharmacy-related waste, which is defined as extra medication-related
spending that provides no additional clinical benefits.

PHARMACY-RELATED WASTE ACROSS AMERICA

Drug Trend Report — Trend Drivers 74

For more than 25 years, Express Scripts has worked to eliminate waste in the pharmacy benefit.
Suboptimal pharmacy-related behavior by U.S. consumers wasted more than $418 billion in 2012 —
more than what the country spends in total on prescription drugs.1 The amount of waste varies greatly by
state, but the highest one-third of waste occurs in the Southeast. The states with the highest waste (more
than $1,600 per person) are Mississippi and Louisiana, with North Carolina and Hawaii not far behind.
Vermont, Minnesota and the Dakotas have the lowest amount of waste per person, but it still adds up to
more than $1,000 in costs that provide no additional health benefits.
To achieve healthier outcomes and save billions of dollars for patients, employers and the government,
we need to drive behavioral changes by making better drug choices, better pharmacy choices and better
health choices.

Footnotes
1. MS Institute for Healthcare Informatics. Declining medicine use and costs: for better or worse? A review of the use of
I
medicines in the United States in 2012. May 2013. Available at: http://tinyurl.com/k2e3yf9. Accessed June 5, 2013.


PATENT EXPIRATIONS
The Patent Expirations section shows newly introduced generics, listed by generic
launch date.

PATENT EXPIRATIONS 2013
BRAND NAME
(GENERIC NAME)

PRIMARY
INDICATION

ESTIMATED
ANNUAL
SALES
(MILLIONS)

GENERIC
LAUNCH
DATE

EXCLUSIVITY
(YES OR NO)

$21

Aug 12

Y

Campral® (acamprosate)

Alcohol Dependence

Temodar® (temozolomide)

Glioblastoma Multiforme and
Anaplastic Astrocytoma

$423

Aug 12

Y

Ranexa® (ranolazine)

Angina

$443

Aug 1

Y

Stalevo® (carbidopa/levodopa/
entacapone)

Parkinson’s Disease

$139

July 25

Y

Glumetza® (metformin extended
release)

Diabetes

$144

July 23

Y

Aricept® 23mg (donepezil)

Alzheimer’s Disease

$93

July 24

Y

Lamictal® ODT™ (lamotrigine
orally disentegrating tablets)

Epilepsy

$51

July 16

Y

Trilipix® (fenofibric acid delayed
release 45mg, 135mg)

Hyperlipidemia

$554

July 15

N

Dacogen® (decitabine for injection)

Myelodysplastic Syndrome

$260

July 11

N

Prandin® (repaglinide)

Diabetes

$200

July 11

N

ProCentra® (dextroamphetamine
oral solution)

Attention Deficit Hyperactivity
Disorder and Narcolepsy

$10

July 10

N

Metrogel® (metronidazole topical
gel 1%)

Rosacea

July 1

N

Rilutek® (riluzole)

Amyotrophic Lateral
Sclerosis

June 18

N

$110
$64


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